Virginia Premier Advantage Gold and Platinum Summary of ......Virginia Premier Advantage Gold (HMO)...

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Summary of Benefts 2020 Virginia Premier Advantage Gold (HMO) H9877-002 Virginia Premier Advantage Platinum (HMO) H9877-003 This Summary of Benefts includes service areas in Central Virginia and Eastern Virginia H9877_0719-SBGP20-800073_M F&U Date - 08/26/2019

Transcript of Virginia Premier Advantage Gold and Platinum Summary of ......Virginia Premier Advantage Gold (HMO)...

  • Summary of Benefts 2020

    Virginia Premier Advantage Gold (HMO) H9877-002 Virginia Premier Advantage Platinum (HMO) H9877-003

    This Summary of Benefts includes service areas in Central Virginia and Eastern Virginia

    H9877_0719-SBGP20-800073_M F&U Date - 08/26/2019

  • 2020 Central Virginia Service Area

    Virginia Premier Advantage Gold and Advantage Platinum

    Service Area – 26 cities/counties

    Amelia, Brunswick, Caroline, Charles City, Charlotte, Chesterfeld, Colonial Heights City, Cumberland, Dinwiddie, Goochland, Halifax, Hanover, Henrico, Hopewell City, King and Queen, King William, Louisa, Lunenburg, Mecklenburg, New Kent, Nottoway, Petersburg City, Powhatan, Prince George, Richmond City, and Sussex

    2020 Eastern Virginia Service Area

    Virginia Premier Advantage Gold and Advantage Platinum

    Service Area – 21 cities/counties

    Chesapeake City, Emporia City, Essex, Franklin City, Gloucester, Greensville, Hampton City, Isle of Wight, James City, Mathews, Middlesex, Newport News City, Norfolk City, Poquoson City, Portsmouth City, Southampton, Suffolk City, Surry, Virginia Beach City, Williamsburg City, and York

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  • Let’s talk about Virginia Premier Advantage Gold (HMO) and Advantage Platinum (HMO) Plans (H9877-002 and H9877-003) This summary will let you fnd out more about our Gold and Platinum plans including the medical and drug services they cover.

    Virginia Premier Advantage Gold and Advantage Platinum are Medicare Advantage HMO plans with a Medicare contract. Enrollment in the plans depends on contract renewal.

    The beneft information in this document is a summary of what we cover and what you pay. It does not list every service we cover or every limitation or exclusion from our plan. To get a complete list of services we cover, please call our Member Services department to request a copy of the Evidence of Coverage or visit us online at VirginiaPremier.com.

    To be eligible for our HMO plans:

    To join Virginia Premier Medicare Advantage Gold (HMO) or Advantage Platinum (HMO), you must be entitled to Medicare Part A, be enrolled in Medicare Part B and live in the service area of our plans. Please see the map of our service area on the inside cover of this booklet.

    Note: As a member you must select an in-network doctor to act as your Primary Care Provider (PCP). However, you can see one of our Specialist doctors without a referral from your PCP. We do encourage all of our members to seek Specialist referrals with their PCP.

    How to contact us:

    If you are not a member of our plan, please contact us toll-free at 1-833-280-1216 (TTY: 711) for more information. You will be connected with a licensed Medicare Beneft Advisor.

    If you are a member of our plan, please call us toll-free at 1-877-739-1370 (TTY: 711) to speak to a Medicare Benefts Representative. Our representatives are available 7 days a week, 8 am to 8 pm October 1 through March 31. From April 1 through September 30, they are available Monday through Friday 8 am to 8 pm. On certain holidays and weekends from April 1 through September 30, you call will be handled by our automated phone system.

    Visit our web site at VirginiaPremier.com.

    What doctors and hospitals you can use:

    We have a network of doctors, hospitals, and other providers. If you use providers that are not in our network, the plan may not pay for these services.

    You can see our plan’s provider directory and view our prescription drug formulary on our website at VirginiaPremier.com.

    This document is available in other formats such as large print and audio.

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    http://medicare.virginiapremier.comhttp://virginiapremier.comhttp://virginiapremier.com

  • To fnd out more about the coverage and costs of Original Medicare, look in the current “Medicare & You” handbook. View it online at medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

    Virginia Premier is an HMO and HMO SNP organization with a Medicare contract. Enrollment in Virginia Premier depends on contract renewal. This information is not a complete description of benefts. Contact the plan for more information. Virginia Premier Health Plan, Inc. is a fully-owned subsidiary of VCU Health. Other physicians and providers are available in our network.

    Monthly Premium, Deductible and Out-of-Pocket Limits

    Premiums and Benefts Medicare Advantage Gold (HMO)

    Medicare Advantage Platinum (HMO)

    Monthly Premium $0 $29

    Medical Deductible $0 $0

    Pharmacy (PART D) Prescription Drug Deductible

    $250 for Tier 3, Tier 4 and Tier 5 $0 for Tier 1 and Tier 2

    $5,900 annually. After you reach this amount through co-pays, coinsurance and other medical services we will pay the full cost of covered services for the rest of the year.

    $100 for Tier 3, Tier 4 and Tier 5 $0 for Tier 1 and Tier 2

    $5,900 annually. After you reach this amount through co-pays, coinsurance and other medical services we will pay the full cost of covered services for the rest of the year.

    Out-of-pocket Maximum (Does not include prescription drugs)

    How can we charge a $0 or very low premium? Virginia Premier is reimbursed each month from the Centers for Medicare & Medicaid Services (CMS) for our covered members. We become your insurer of Medicare benefts in place of CMS and Original Medicare.

    Covered Medical and Hospital Benefts

    Inpatient Hospital1 $300 co-pay for days 1 through 5 $0 co-pay for days 6 and beyond

    $250 co-pay for days 1 through 5 $0 co-pay for days 6 and beyond

    Outpatient Hospital1 Outpatient Hospital: $325 co-pay Ambulatory Surgical Center: $275 co-pay

    Outpatient Hospital: $300 co-pay Ambulatory Surgical Center: $250 co-pay

    Doctor Visits Primary care provider: $0 co-pay Specialists: $45 co-pay

    Primary care provider: $0 co-pay Specialists: $35 co-pay

    Preventive Care Screenings

    Our plan covers many preventive services at $0 co-pay when you get services with an in-network provider.

    Our plan covers many preventive services at $0 co-pay when you get services with an in-network provider.

    Annual Physical Exam* $0 co-pay $0 co-pay

    * If you receive either an annual wellness exam or annual physical exam you will receive a$25 incentive just for getting the exam

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    https://medicare.gov

  • Hearing Services

    Medicare-Covered Exams to Diagnose and Treat Hearing and Balance Issues

    You pay $45 co-pay You pay $35 co-pay

    Routine Hearing Exam You pay $0 for one routine hearing exam and ftting annually

    You pay $0 for one routine hearing exam and ftting annually

    Hearing Aid Allowance Up to $750 every 3 years for a hearing aid. Major discounts with our hearing aid supplier. Extended warranty and 1 year of batteries.

    Up to $1,000 every 3 years for a hearing aid. Major discounts with our hearing aid supplier. Extended warranty and 1 year of batteries.

    Outpatient Care and Services

    Diagnostic Services, Labs and Imaging1Note: Cost sharing will vary depending on the service and where it is given

    • Therapeutic radiology services:$60

    • X-ray services: $45

    • Diagnostic radiology (CT, MRI,etc.): $275-$325 depending onservice location.

    • Labs and testing: $15

    • Therapeutic radiology services:$50

    • X-ray services: $35

    • Diagnostic radiology (CT, MRI,etc.): $250-$300 depending onservice location

    • Labs and testing: $0

    Emergency Care

    Beneft Category Medicare Advantage Gold (HMO)

    Medicare Advantage Platinum (HMO)

    Emergency Room $90 per visit Note: If you are admitted to the hospital within 3 days, you do not have to pay your share of the cost for the emergency room

    $90 per visit Note: If you are admitted to the hospital within 3 days, you do not have to pay your share of the cost for the emergency room

    Worldwide Emergency Care

    Up to $50,000 per year Up to $50,000 per year

    Dental

    Routine Dental Services You pay $0 for 2 cleanings, 2 fuoride treatments, 2 exams, and 1 bitewing and 1 panoramic X-ray every 3 years

    You pay $0 for 2 cleanings, 2 fuoride treatments, 2 exams, and 1 bitewing and 1 panoramic X-ray every 3 years

    Comprehensive Dental Services

    50% coinsurance for fllings, extractions, crowns, implants and bridges up to $1,000 per year

    50% coinsurance for fllings, extractions, crowns, implants and bridges up to $1,000 per year

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  • Vision

    Beneft Category

    Medicare-Covered Vision Services

    Routine Vision Care

    Eyewear

    Mental Health Services

    Inpatient Stays1

    Outpatient Group Therapy/ You pay $40 co-pay You pay $30 co-pay Individual Therapy Visit1

    You pay $300 per day for days 1-5 You pay $0 days 6-150

    You pay $250 per day for days 1-5 You pay $0 days 6-150

    Rehabilitative Services

    Medicare Advantage Gold (HMO)

    Medicare Advantage Platinum (HMO)

    You pay $45 co-pay You pay $35 co-pay

    You pay $0 for 1 exam annually You pay $0 for 1 exam annually

    $150 allowance toward glasses/ $200 allowance toward glasses/ contacts annually contacts annually

    Cardiac Rehabilitation Services1

    Intensive Cardiac Rehabilitation Services1

    Pulmonary Rehabilitation Services1

    Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD)1

    Skilled Nursing Facility (SNF)1

    Physical Therapy/ Occupational Therapy/ Speech Language Pathology1

    Medicare-covered $50 co-pay Medicare-covered $50 co-pay

    Medicare-covered $100 co-pay Medicare-covered $100 co-pay

    Medicare-covered $30 co-pay Medicare-covered $30 co-pay

    Medicare-covered $30 co-pay Medicare-covered $30 co-pay

    You pay $0 days 1-20 You pay $160 per day for days 21-100

    You pay $0 days 1-20 You pay $140 per day for days 21-100

    You pay $40 co-pay You pay $35 co-pay

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  • Additional Benefts

    Beneft Category Medicare Advantage Gold (HMO)

    Medicare Advantage Platinum (HMO)

    Ambulance Services -Ground2

    You pay $275 co-pay You pay $250 co-pay

    Ambulance Services - Air2 20% coinsurance 20% coinsurance

    Transportation1 $0 co-pay for 6 one-way trips or 3 round trips per year

    $0 co-pay for 4 one-way trips or 2 round trips per year

    Medicare Part B Drugs1 You pay 20% of the cost for chemotherapy drugs You pay 20% of the cost for other Part B drugs

    You pay 20% of the cost for chemotherapy drugs You pay 20% of the cost for other Part B drugs

    Footcare (Podiatry Services) Medicare-Covered Services1

    You pay $45 co-pay You pay $35 co-pay

    Routine Footcare You pay $20 co-pay per visit, 4 visits annually

    You pay $20 co-pay per visit, 8 visits annually

    Durable Medical Equipment and Supplies1

    You pay 20% of the cost You pay 20% of the cost

    Fitness Beneft Fitness center membership You pay nothing at participating facilities

    Fitness center membership You pay nothing at participating facilities

    Chiropractor Routine care not covered $20 co-pay for Medicare-covered services

    $0 co-pay for 6 routine care visits annually $20 co-pay for Medicare-covered services

    Over-the-Counter (OTC) Drug Beneft

    $50 mail order allowance per quarter (does not carry over)

    Meals ordered by Physician or Plan Care Coordinator after discharge from inpatient or skilled nursing facility stay. Member receive up to 28 meals (2 per day) for qualifed discharge.

    $60 mail order allowance per quarter (does not carry over)

    Meals ordered by Physician or Plan Care Coordinator after discharge from inpatient or skilled nursing facility stay. Member receive up to 28 meals (2 per day) for qualifed discharge.

    Meal Beneft

    1 You do not need a referral to receive covered services from providers. However, certain procedures, services and drugs marked with a 1 may need approval in advance from your plan. This is called “prior authorization.” Please contact your PCP or refer to the Evidence of Coverage (EOC) for services that require a prior authorization from our plan. The provider/pharmacy network may change at any time. You will receive notice when necessary.

    2 Authorization required for non-emergency services

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  • Outpatient Prescription Drugs

    Beneft Category Medicare Advantage Gold (HMO)

    Medicare Advantage Platinum (HMO)

    Pharmacy Deductible $250 annual deductible for Tier 3, Tier 4, and Tier 5 $0 for Tier 1 and Tier 2

    $100 annual deductible for Tier 3, Tier 4, and Tier 5 $0 for Tier 1 and Tier 2

    Initial Coverage (after you pay your deductible)

    You pay the following until your total yearly drug costs reach $4,020. Total yearly drug costs are the total drug costs paid by both you and our plan.

    Outpatient Prescription Drugs – Initial Coverage

    Advantage Gold Plan Retail Rx 31-day supply Retail Rx 90-day supply

    Mail Order 90-day

    Tier 1: Preferred Generic You pay $2 You pay $6 You pay $2

    Tier 2: Non-Preferred Generic You pay $15 You pay $45 You pay $15

    Tier 3: Preferred Brand You pay $47 You pay $141 You pay $117.50

    Tier 4: Non-Preferred Drug You pay $100 You pay $300 You pay $250

    Tier 5: Specialty Tier You pay 28% Not offered Not offered

    Advantage Platinum Plan Retail Rx 31-day supply Retail Rx 90-day supply

    Mail Order 90-day

    Tier 1: Preferred Generic You pay $2 You pay $6 You pay $2

    Tier 2: Non-Preferred Generic You pay $12 You pay $36 You pay $12

    Tier 3: Preferred Brand You pay $47 You pay $141 You pay $117.50

    Tier 4: Non-Preferred Drug You pay $100 You pay $300 You pay $250

    Tier 5: Specialty Tier You pay 31% Not offered Not offered

    Note: Specialty drugs are limited to a 31-day supply. Cost sharing may change if you qualify for "Extra Help." To fnd out if you qualify, please contact the Social Security Offce at 1-800-772-1213, Monday - Friday 7 am to 7 pm. TTY users should call 1-800-325-0778. For more information on the additional pharmacy-specifc cost sharing and the phases of the beneft, please call us or access our “Evidence of Coverage” online.

    If you reside in a long-term care facility, you pay the same as a standard retail pharmacy.

    You may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-network facility.

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  • Coverage Gap

    Most Medicare drug plans have a coverage gap (also called the “donut hole”.) This means that there’s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug costs (including what our plan has paid and what you have paid) reaches $4,020.

    After you enter the coverage gap, you pay 25% of the plan’s costs for covered brand name drugs until your costs total $6,350 which is the end of the coverage gap. Not everyone will enter the coverage gap.

    Coverage Gap

    Advantage Gold Plan Retail Rx 31-day supply Retail Rx 90-day supply

    Mail Order 90-day

    Tier 1: Preferred Generic You pay $2 You pay $6 You pay $2

    Tier 2: Non-Preferred Generic You pay $15 You pay $45 You pay $15

    Advantage Platinum Plan Retail Rx 31-day supply Retail Rx 90-day supply

    Mail Order 90-day

    Tier 1: Preferred Generic You pay $2 You pay $6 You pay $2

    Tier 2: Non-Preferred Generic You pay $12 You pay $36 You pay $12

    For all other formulary drugs, after you enter the coverage gap, you pay 25% of the plan's cost for covered brand name drugs, until your costs total $6,350, which is the end of the coverage gap.

    Catastrophic Phase

    After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $6,350 you pay $3.60 co-pay for those generic or preferred generic with a retail price under $72 and 5% of the cost for those with a retail price greater than $72. For brand-name drugs you pay $8.95 co-pay for those drugs with a retail price under $179 and 5% coinsurance for those with a retail price over $179.

    Find Your Doctors, Hospitals, Pharmacies and Research Our Drug Formulary Providers/Pharmacies

    You can easily fnd a list of our providers online. Visit VirginiaPremier.com to fnd the most up-to-date list of our providers, including doctors, hospitals, urgent care centers and pharmacies in our network. You can always call one of our Medicare Member Services Representatives at 1-877-739-1370 (TTY: 711) to ask about providers and facilities in our network. From October 1 to March 31, we are open daily from 8 am to 8 pm, 7 days a week. From April 1 through September 30, we are open Monday through Friday, 8 am to 8 pm. On certain holidays and weekends from April 1 through September 30, your call will be handled by our automated phone system.

    Formulary

    You can check our full formulary online at VirginiaPremier.com or call one of our Medicare Member Services Representatives at the number above. Medicare Beneft Advisors who are licensed sales representatives are also available toll free at 1-833-280-1216.

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    http://virginiapremier.comhttp://virginiapremier.com

  • H9877_0817-NND-600001 AI 08/25/2017

    Notice of Non-Discrimination

    Virginia Premier Health Plan, Inc. (Virginia Premier) complies with applicable Federal civil rights

    laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

    Virginia Premier does not exclude people or treat them differently because of race, color,

    national origin, age, disability, or sex.

    Virginia Premier:

    Provides free aids and services to people with disabilities to communicate

    effectively with us, such as:

    o Qualified sign language interpreters

    o Written information in other formats (large print, audio, accessible

    electronic formats, other formats)

    Provides free language services to people whose primary language is not

    English, such as:

    o Qualified interpreters

    o Information written in other languages

    If you need these services, contact Member Services at 1-877-739-1370, TTY: 711.

    If you believe that Virginia Premier has failed to provide these services or discriminated in

    another way on the basis of race, color, national origin, age, disability, or sex, you can file a

    grievance with:

    Virginia Premier

    Attn: Grievances & Appeals Manager

    P.O. Box 5244

    Richmond, VA 23220

    1-877-739-1370, TTY: 711

    Fax: 800-289-4970

    [email protected]

    You can file a grievance in person or by mail, fax, or email. If you need help filing a

    grievance, the Grievances & Appeals Manager is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human

    Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint

    Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services

    200 Independence Avenue, SW

    Room 509F, HHH Building

    Washington, D.C. 20201

    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

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    mailto:[email protected]://ocrportal.hhs.gov/ocr/portal/lobby.jsfhttp://www.hhs.gov/ocr/office/file/index.html

  • H9877_0817-MLI-500009 Accepted 08/20/2017

    Multi-Language Insert Multi-Language Interpreter Services

    ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-877-739-1370 (TTY: 711).

    ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-877-739-1370 (TTY: 711).

    주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.

    1-877-739-1370 (TTY: 711) 번으로 전화해주십시오.

    CHÚ Ý: Nếu bạn nói Tiếng Việt, chúng tôi có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Xin gọi số 1-877-739-1370 (TTY: 711).

    注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電 1-877-739-1370

    (TTY: 711)。

    1370-739-877-1، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم العربيةملحوظة: إذا كنت تتحدث

    .(TTY :711) الهاتف النصي)

    PAUNAWA: Kung nagsasalita ka ng Tagalog, may mga magagamit kang libreng serbisyo ng tulong sa wika. Tumawag sa 1-877-739-1370 (TTY: 711).

    فراهم می باشد. با شماره شما برای رایگان بصورت زبانی تسھیالت کنید، می صحبت فارسی زبان هب اگر :هتوج 1-877-739-1370 (TTY: 711) بگیرید تماس.

    ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡፡ ወደ ሚከተለው

    ቁጥር ይደውሉ 1-877-739-1370 (መስማት ለተሳናቸው: 711).

    توجہ ديں: اگر آپ اردو بولتے ہيں تو، زبان سے متعلق اعانت کی خدمات، آپ کے ليے مفت دستياب ہے۔

    1-877-739-1370 (TTY: 711) پر کال کريں۔

    ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-877-739-1370 (ATS: 711).

    ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги

    перевода. Звоните 1-877-739-1370 (линия TTY: 711).

    ध्यान दें: यदद आप ह िंदी बोलते ैं तो आपके ललए मुफ्त में भाषा स ायता सेवाएिं उपलब्ध ैं।

    1-877-739-1370 (TTY: 711) पर कॉल करें।

    ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-877-739-1370 (TTY: 711).

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  • মননোনযোগ দিনঃ আপদন যদি বোাংলোনে কথো বলনে পোনেন, েোহনল দনঃখেচোয় ভোষো সহোয়েো পদেনষবো উপলব্ধ আনে। ফ োন করুন 1-877-739-1370 (TTY: 711)

    YI LE: I balè u pot tila hop won ngim bod i kobol mahop i la hola wè ni hop won, u saa béé to yom. Sébél 1-877-739-1370 (TTY: 711).

    GENU NTI: Ọ buru na ina asu asusu Igbo, enyemaka na-ahazi asusu, bu n’efu, diri gi mgbe niile. Kpoo nomba ndi a 1-877-739-1370 (TTY: 711).

    AKIYESI: Bi o ba nsọ èdè Yorùbá, ọfé ni iranlọwọ lori èdè wa fun yin. Ẹ pe ẹrọ-ibanisọrọ yi 1-877-739-1370 (TTY: 711).

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    SummaryofBenefitsGoldPlat2020.pdfNotice of Non-Discrimination No name - wo carats.pdfMLI.pdf